The Minuteman Implant Club (MIC)

Make Checks payable to MIC and Send To:

Minuteman Implant Club
251 South Street
Foxboro, MA 02035-2707
Thank you for your support!!
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*Yes, we/I want to join and support the Minuteman Implant Club. Here are our dues for one year. This entitles us to receive the newsletter and to vote at club meetings.

Please print: Date: __________ Dues are $15.00 per year. I/We are signing up/renewing for ___ year(s)

Your Title & name: _________________________________________________________________

Spouse/Partner name: ______________________________________________________________

Children names/DOB: ___________________________________________________________________________

Address:_____________________________________________

City:_____________________State: ____ Zipcode: _______

E-mail: ____________________________________________Telephone _______________V/ TDD_______________

Dues_________________ Donation:________________

Person who has implant:______________________

Permission to be listed in MIC member Directory Y/N The Minuteman Implant Club (MIC)

This can be printed out on your printer. Make as many copies as you want. We are working on a page link to pay your membership fee on your credit card, or to use your PayPal account with our Internet provider.

 

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